DS-13-3760 1'2 �� 0 (�'lp Miami Shores Village
Building Department FE -3
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 20
BUILDING Permit Nr
PERMIT APPLICATION Master Permit No.� C
Permit Type: BUILDING ROOFING
JOB ADDRESS: i (A oW to� �{ O'
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:
Is the Building Historically Designated: Yes
OWNER: Name (Fee
City:
State:
NO Flood Zone:
Tenant/Ussee Name: Phone#:
Email:
113--73()141
CONTRACTOR: Company Name- 1�,7. � A t' � N� G�11 l7 Phone#1 6,6 -7-81
Address: L�3J� O W
City: & tiw aE ?I K)T---S State: , Zip:
Qualifier Name:
State Certification or Registration #: CG C 06S6% Certificate of Competency #:
Contact Phone#: TbbY Email Address:
DESIGNER: Archi ct/Engineer: Phones
Value of Work for this Permit: $ 4j J Square/Linear Footage of Work: 100
Type of Work: ❑Addition ❑Alteration ONew ❑Repair/Replace ODemolition
Description of Work: LAM hi N 4 WJ r4 Two i6Dt,
Color thru file.-
Submittal
le.
Submittal Fee $ Permit Fee $
Scanning Fee $
Radon Fee $
Notary $ Training/Education Fee $
CCF
CO/CC $
DBPR $ Bond $
Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State
zip
zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR N04 RICE OF COMMENCEMENT."
Notice to Applicant: As a conditi n to th issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a cop of the otice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to att chmen . Also, a certified copy of the recorded notice of commen ment must be posted at the job site
for the first inspect' w ccur seven (7) days afier the building permit is issu In th bsenc suc posted notice, the
inspection will not b approv ,a a reinspection fee will be charged. l q
uwne or;�
a t
The foe ing instrumen as ac wledged bef me this
day of . �� , 20 1 1 , by 1 ,
wh s rsonally known to a or who Ls produced
As identification and who did take an oath.
NOTARY UBLIC:
Sign: �l
Print:
My Commission Expires:
APPROVED BY
Signature
The foregoing instrument was acknowledged before me this
day of 20 , by k C-A�P?3
who is personally known to me or who has produced
%%,uu �1lh„J
as identification and wOd taker'
NOTARY PUBLIC: °o.
Plans Examiner
Structural Review
My Commission Expires:
(Revised 5/2/2012)('Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007)